Patients with impaired T cell immunity, like those on immunosuppressants (IMS) for autoimmune diseases, are at higher risk of herpes zoster (HZ). Studies looking at the relative risk of HZ associated with corticosteroids, biologics or conventional disease modifying agents (cDMARD) have generated conflicting results. This study aimed to determine the association of these agents with the risk of HZ in patients with autoimmune diseases through a meta-analysis.
A systematic search with MEDLINE, EMBASE, Google, Google Scholar, CENTRAL, CAB Direct, CINAHL, Web of Knowledge, and PubMed for studies published in English (Jan 1946 - Feb 2015) and reporting HZ outcomes in adults with autoimmune diseases on IMS was conducted. Search terms related to HZ, autoimmune diseases and IMS were used. For randomized controlled trials (RCT), due to rare events, the Mantel-Haenszel method with continuity correction was performed to estimate the pooled odds ratio (OR) and 95% confidence interval [CI] for HZ associated with various IMS. For observational studies (OBS), adjusted ORs were pooled separately using the inverse variance method.
Out of the 3756 identified studies, 44 were included (n= RCT: 47,152, OBS: 3,117,387). Biologics were associated with a greater risk of HZ than control (RCT: OR 1.69, 95% CI 1.09-2.62; OBS: 1.48, 95% CI 1.31-1.67). In RCT, the OR of TNF blockers was 2.10 (95% CI 1.17-3.77) but that of non-TNF blockers was not significantly different from control (i.e. placebo/ non-use). A small increased risk of HZ with cDMARD (OR 1.20, 95% CI 1.15-1.25) was observed in OBS but not in RCT; and the risk was lower compared to biologics (OBS: OR 1.23, 95% CI 1.03-1.48, not significant in RCT). Combinations with biologics was associated a greater risk of HZ (OBS: OR 2.47, 95% CI 1.91-3.19). HZ risk was also increased with corticosteroid use alone versus non-use (OBS: OR 1.78, 95% CI 1.72-1.84).
This study showed an increased risk of HZ in patients receiving biologics, especially TNF blockers. The trend was also observed with corticosteroids, less so for cDMARD and higher with combinations involving biologics. These findings raise the issue of prophylaxis with zoster vaccines in patients initiating IMS for autoimmune diseases.
Merck Canada Inc:
V. Kalashnikov, None
K. Richardson, None
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